208 Sahin et al World J Emerg Med, Vol 7, No 3, 2016

Original Article

Code Blue evaluation in children's hospital

Kubra Evren Sahin, Oktay Zeki Ozdinc, Suna Yoldas, Aylin Goktay, Selda Dorak
Department of Anesthesiology, Dr. Behcet Uz Children Hospital, Konak, Izmir 35210, Turkey
Corresponding Author: Kubra Evren Sahin, Email: kubraevren@gmail.com

BACKGROUND: True alarm rate of the Code Blue cases is at a low level in the Dr. Behet Uz
Children's Hospital in zmir. This study aims to analyse the use of the Code Blue alarm cases in the
children's hospital.
METHODS: This retrospective clinical study evaluated the age and the gender of the cases, the
arriving time of the Code Blue team, the date and time of the Code Blue Call, the reasons of the Code
Blue Call, and the verification which were all obtained from the Code Blue forms of the hospital dated
between January 2014 and January 2015. The data of 139 Code Blue cases' forms were investigated
and was divided into two groups: before and after the education containing 88 and 51 cases,
respectively.
RESULTS: Conversive disorder (26% to 13%, P<0.01), syncope (21.5% to 19.6%, P<0.01),
convulsion (17% to 13.7%, P<0.01), hypoglycemia (4.5% to 3.9%, P<0.01), anxiety (4.5% to 1.9%,
P<0.01), head trauma due to syncope (4.5% to 0%), cardiac arrest (1.1% to 0%), respiratory
difficulties (2.2% to 1.9%, P<0.01), suspicion of myocardial infarction (2.2% to 1.9%, P<0.01), fall
from stairs (2.2% to 0%) and agitation cases (1.1% to 0%) were reduced, however, the hypertension
cases were dramatically increased (3.4% to 29.4%, P<0.01) owing to the hospital staff's education.
The Pearson's correlation coefficient before and after education was 0.837. About 97.8% of the Code
Blue cases were false calls with female greater than male (P<0.01).
CONCLUSION: The results of this study show that more education is required for the hospital's
staff and a new color code that is to say pre-diagnosis team should be formed.
KEY WORDS: Code Blue; Cardiopulmonary resuscitation; Hospital arrest
World J Emerg Med 2016;7(3):208212
DOI: 10.5847/wjem.j.19208642.2016.03.008

INTRODUCTION system has become obligatory in 2009 with a formal

Code Blue is the emergency management system
that is formed by the cases in need of emergency medical
intervention, case relatives or hospital staff. The process
consists of a code that is announced by healthcare
professionals and responded to by the designated
personnel for intervention of cardiac arrest cases.[15]
It is an emergency management tool that provides the
quickest intervention. "Code Blue" is the only color
code used for the same emergency case worldwide.
Code Blue was used for the first time in Kansas Bethany
Medical Center in the United States of America and
common usage in our country was established in 2008
by implementation of service quality standards.[2] This
notification by the Ministry of Health and Patient and
Personnel Safety Regulations in 2011.[3] The successes of
Code Blue was not compared with each other in previous
studies in the related literature in terms of the effects of
before-and-after education of the hospital staff.[612] This
study presents the comparisons of the Code Blue cases
where before-and-after education of the hospital staff
is investigated in the Children Hospital. "Code Blue"
responders and teams are determined in Dr. Behet Uz
Children's Hospital for quick intervention of cases in
need of emergency medical intervention, case relatives
or hospital staff. Three separate teams responsible for
Code Blue are formed in our hospital for faster and more

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2016 World Journal of Emergency Medicine
World J Emerg Med, Vol 7, No 3, 2016
efficient resuscitation. The Code Blue notification form
is filled and sent to the Quality Management Department
by the Code Blue responder after the intervention. These
stages are similar to the other processes which are "run
the code" and "blue code".[4,5] The inspected Code Blue
forms are dated from January 2014 to January 2015
retrospectively as the Code Blue Responding Team and
evaluated the application of Code Blue in the hospital.
METHODS
The retrospective clinical study evaluated the age
and the gender of the cases, the arrival time of the Code
Blue team, the date and time of the Code Blue Call,
the reasons of the Code Blue Call, and the verification
of the Code Blue codes which were obtained from the
Code Blue forms of the Hospital dated from January
2014 to January 2015. There are approximately 100 000
emergency service admissions (including walk in clinics
during night shifts) and 500 000 policlinics admissions
annually. Three separate Code Blue teams were formed
due to the physical characteristics of the Dr. Behet Uz
Children's Hospital (Policlinics, Surgery and Emergency
service Code Blue Call teams). These teams are not
composed of fixed staff, which include the doctors and
the nurses. They work on a rotating shift schedule.
All the teams used the same Code Blue notification
forms controlled by the Hospital's Quality Management
Department where all of the forms are combined and
evaluated. Fourteen different reasons of Code Blue Call
were detected during the evaluation of Code Blue Case
Report Forms. Calls for "arrest" were grouped as true
calls and "non-arrest" cases were grouped as false calls.
Calls were grouped as calls during work hours (weekdays
between 08:0016:00) and calls during shifts (weekdays
between 16:0008:00 and weekend). Calls during official
holidays were included in calls during shifts. Arrival time
of the team to the place of the event was assumed as the
time between Code Blue Call and the arrival of the team
and recorded in minutes.
The process followed quality standards in accordance
with AHA 2010 guidelines. The data from 139 Code Blue
case forms were investigated and was approved by the
hospital ethics committee. Cases developed in operation
room and intensive care units were not considered. The
overall code blue forms were divided into two groups.
The first group had 88 cases during the first 9 months
before the education of the hospital staff while the
second group consisted of 51 after the education of the
209
staff. The data was analyzed with SPSSv21 program
in terms of cross-tabulation, frequency, mean, standard
deviation and percentage.
RESULTS
Difference between diagnosis in the two groups
(before and after education) were analyzed. Conversive
disorder (from 26% to 13%, P<0.01), syncope (from
21.5% to 19.6%, P<0.01), convulsion (from 17% to
13.7%, P<0.01), hypoglycemia (from 4.5% to 3.9%,
P<0.01), anxiety (from 4.5% to 1.9%, P<0.01), head
trauma due to syncope (from 4.5% to 0%, P<0.01),
cardiac arrest (1.1% to 0%), respiratory difficulties
(from 2.2% to 1.9%, P<0.01), suspicion of myocardial
infarction (from 2.2% to 1.9%, P<0.01), fall from stairs
(from 2.2% to 0%) and agitation cases (from 1.1% to
0%) were reduced, however, the hypertension cases
were dramatically increased (from 3.4% to 29.4%,
P<0.01) owing to the hospital staff education. The
Pearson's correlation coefficient between before-and-
after education was 0.837. The mean time to arrival of
the cases before education was 106.2 seconds while the
mean time of arrival of the cases after education was
73.2 seconds.
There were 88 Code Blue Calls in the pre-education
group between January-October 2014. Among them,
53 (60.2%) cases were females, while 35 (39.8%) were
males. One hundred and thirty-six (97.8%) of the Code
Blue cases were false calls where the number of false
calls for female was dramatically greater than for males
(P<0.01). The youngest of the cases was 2 years old and
the oldest was 84 years old and the mean age was 27
years old. The age distribution of the cases was shown
in Figure 1. Distribution of the personnel calling code
blue was 13 (14.7%) doctors, 22 (25%) nurses, and 53
(60.2%) other hospital staff. Arrival time of the team
to the Code Blue cases ranged from 1 to 5 minutes and
25
Before education
The number of cases
20 After education
15
10
5
0
10 20 30
50 40 60 70 80 90
Ages
Figure 1. The age distribution of the cases.
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 210 Sahin et al World J Emerg Med, Vol 7, No 3, 2016

the mean duration was 106.2 seconds. Arrival time was
1 minute in 42% of the cases, 2 minutes in 41% of the
cases, 3 minutes in 16% of the cases and 5 minutes in
1% of the cases. Moreover, 68 (78%) of Code Blue Calls
were performed during work hours and 20 (22%) were
performed during shift hours. The most frequent Code
Blue calls time interval was 09:0012:00.
After education, 51 Code Blue Calls occurred
between the dates of October 2014 to January 2015.
Among them, 35 (68.6%) cases were females and 16
(31.4%) were males. The youngest of the cases was 3
months old and the oldest was 67 years old with a mean
age of 22.61 years old. The age distribution of the cases
was shown in Figure 1. Distribution of the personnel
calling code blue was 6 (11.7%) doctors, 13 (25.4%)
nurses, and 32 (62.7%) other hospital staff. Arrival
time of the team to the Code Blue cases ranged from 1
to 5 minutes and the mean duration was 73.2 seconds.
Arrival time was 1 minute in 82.4% of the cases, 2
minutes in 13.7% of the cases, and 3 minutes in 3.9%
of the cases. Moreover, 44 (86.3%) of Code Blue Calls
were performed during work hours and 7 (13.7%) were
performed during shift hours. The most frequent Code
Blue Calls time interval was 09:0012:00.
In total evaluation of 139 Code Blue Calls, which
occurred between the dates of January 2014 to January
2015, 88 (63.3%) of 139 cases were females, and 51
(36.7%) were male. The youngest patient was 3 months
old and the oldest was 84 years old with a mean age of
26.01 years old. Distribution of the personnel calling
code blue was 19 (14%) doctors, 35 (25%) nurses, 85
(61%) other hospital staff. One hundred and eleven
(79.9%) of Code Blue Calls were performed during work
hours and 28 (20.1%) were performed during shift hours.
One (0.7%) of the code blue calls were for cardiac arrest,
2 (1.4%) of the code blue calls were for respiratory arrest,
and 136 (97.8%) were for non-arrest cases. Respiratory
50
The number of cases
and cardiac arrest cases responded to cardiopulmonary
resuscitation in 1 minute. They were discharged after an
interval of observation in the intensive care unit. Arrival
time of the team to the Code Blue case ranged from 1
to 5 minutes and the mean duration was 94.2 seconds.
Arrival time was 1 minute in 56.8% of the cases, 2
minutes in 30.9% of the cases, 3 minutes in 11.5%, and 5
minutes in 7% of the cases.
Education decreased arrival time of the Code Blue
team dramatically in Figure 2 where the mean time of
arrival of the cases before education was 106.2 seconds
while the mean time of arrival after education was
73.2 seconds. Moreover, most diagnoses of the cases
were affected positively which was given in Table 1
where conversive disorder (from 26% to 13%, P<0.01),
syncope (from 21.5% to 19.6%, P<0.01), convulsion
(from 17% to 13.7%, P<0.01), hypoglycemia (from 4.5%
to 3.9%, P<0.01), anxiety (from 4.5% to 1.9%, P<0.01),
head trauma due to syncope (from 4.5% to 0%), cardiac
arrest (1.1% to 0%), respiratory difficulties (from 2.2%
to 1.9%, P<0.01), suspicion of myocardial infarction
(from 2.2% to 0%), fall from stairs (from 2.2% to 0%)
and agitation cases (from 1.1% to 0%) were reduced,
however, the hypertension cases were dramatically
increased (from 3.4% to 29.4%) owing to the hospital
staff' education.
DISCUSSION
The Code Blue system has been used to deal with
unexpected and emergency cases in the Dr. Behet Uz
Children's Hospital where 139 Code Blue cases were
Table 1. Code Blue diagnosis before-and-after education of the
children's hospital, n (%)
Variables Before education After education P, r*
Cardiac arrest 1 (1.1) 0 (0)
Respiratory arrest 1 (1.1) 1 (1.9)
Conversive disorder 23 (26) 7 (13) <0.01, =1
Syncope 19 (21.5) 10 (19.6) <0.01, =1
Convulsion 15 (17) 7 (13.7) <0.01, =1

40 Before education Hypotension 7 (8) 6 (11.7) <0.01, =1

After education Hypoglycemia 4 (4.5) 2 (3.9) <0.01, =1
30 Anxiety 4 (4.5) 1 (1.9) <0.01, =1
Head trauma due to 4 (4.5) 0 (0)
20 syncope
Hypertension 3 (3.4) 15 (29.4) <0.01, =0.837
10 Respiratory difficulties 2 (2.2) 1 (1.9) <0.01, =1
MI suspicion 2 (2.2) 1 (1.9) <0.01, =1
0 Fall from stairs 2 (2.2) 0 (0)
2 1 3 4 5
Arrival time (minutes) Agitation 1 (1.1) 0 (0)
*
Figure 2. Education decreased arrival times of the Code Blue team. : Statistical difference P, Pearson's correlation coefficient r.

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World J Emerg Med, Vol 7, No 3, 2016
Table 2. The Code Blue Call studies in our country
Number Genders
References of cases
M F
Koltka et al[9] 610 309 (50.6%) 287 (47%)
Canural et al[8] 23
Bal et al[11] 137
Mehel et al[10] 164
Ylmaz et al[12] 65 30 (46.2%) 35 (53.8%)
Murat et al[7] 180 103 (57.2%) 77 (42.7%)
ieki et al[6] 301 183 (60.8%) 118 (39.2%)
Evren ahin et al 139 51 (36.7%) 88 (63.3%)
between January 2014 and January 2015. The overall
results of Code Blue Calls conducted in our country
were summarized in Table 2 where the Code Blue cases
in our hospital were compared with the other studies, 88
(63.3%) of 139 cases were females and 51 (36.7%) were
males. The female rate was significantly higher than
that in the other studies because a large number of child
patients were accompanied by their mothers admitted to
the children's hospital. The mean age of our Code Blue
cases was 26.01 years old, which span from 3 months to
84 years old, was dramatically less than the other studies
in Table 2, owing to the children's hospital cases.[57]
As for the arrival time evaluation, the arrival time of
Code Blue teams of our hospital ranged from 1 to 5 minutes
which was concordant with the standards and the mean
was 1.57 minutes. This was less than the other studies
except one when it was compared with each other.[69,11,12]
When the frequent Code Blue Calls were compared,
ieki et al [6] reported the most frequent hours as
06:0007:00, Murat et al [7] reported as 22:0023:00,
however most frequent hours for Code Blue Calls of our
hospital were between 09:00 and 12:00 due to children
and their parents of our Children's hospital. Meanwhile,
approximately 79.2% the Code Blue Calls were made
during work hours and about 20.8% were made during
shift hours.
Of the 139 total calls which were obtained from
before-and-after staff's education of the hospital, 136
were considered as inconvenient calls. These false call
process forming the basis of our study was frequently
experienced in our hospital. Approximately, 97.8% of
the Code Blue cases were false calls as the code blue
process might be initiated for unnecessary cases. This
rate was higher compared to the other studies in our
country which were 74% by Canural et al,[8] 39.19% by
Koltka et al,[9] 21% by ieki et al,[6] 10% by Murat
et al,[7] 4% by Mehel et al,[10] 0% by Bal et al,[11] 0% by
Ylmaz et al[12] in Table 2, because the staff might initiate
211
Arrival time Frequent code
Mean age False calls
(minutes) blue call hours
4.02 39.19%
8 74%
2.17
1.34 4%
1.81
72 (2792) 2.72 22:0023:00 10%
71.5 (16102) 1.7 06:0007:00 21%
26.01 (0.2584) 1.57 09:0012:00 97.8%
the Code Blue process under any dangerous and at-risk
situations. Moreover, the reason for this was observed as
pressure to the hospital staff by the patient relatives as
the hospital is a busy regional hospital and the relatives
are highly sensitive for their children seeking emergency
medical care. Arrival of an intervention team prevents
development of unnecessary "White Code" calls. Another
reason for these negative higher rates was observed as
the attitude of the hospital staff. Unfortunately, there is
no chance to initiate the colored alarm but Code Blue.
It is obvious that the new colored alarm process and
confirmation step should be required.
In conclusion, it is clear that the awareness of the
true Code Blue events was improved after education of
the hospital staff in the Children's Hospital. The related
cases that do not require emergency medical intervention
lead to personnel mistrust and loss of time during the
verification process, and decrease success rates and loss
of work power. It is obvious that the new colored alarm
process and confirmation step should be required to
improve better Patient and Personnel Safety Regulations
in Turkey.
ACKNOWLEDGMENTS
The author thanks the director of quality directory of the
hospital Unit Nilgn Erin and the unit staff for help data sharing.
Funding: None.
Ethical approval: The Institutional Review Board of the hospital
approved the study. The study was conducted in accordance with
the principles of the Declaration of Helsinki.
Conflicts of interest: We have no conflicts of interest to report.
Contributors: KES and OZO proposed the study and designed the
trials. KES, SY, AG and SD supervised the conduct of the trial and
data collection. OZO managed the data, including quality control.
KES and SY provided statistical analysis on the data; KES, AG
and SD drafted the manuscript, and all authors contributed. KES
takes responsibility for the paper as a whole.
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 212 Sahin et al
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Accepted after revision May 6, 2016